CPT 99305E&M

1st nf care moderate mdm 35

CPT 99305 is billed when a doctor performs the first comprehensive evaluation of a patient newly admitted to a nursing facility or skilled nursing facility, requiring moderate complexity medical decision-making and typically 35 minutes of care.

Showing rates for

National Average

Base Medicare rate

$128.42

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

2.5

PE RVU (NF)

1.31

MP RVU

0.16

Total RVU

3.97

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Document total time spent on the date of encounter when time-based coding is more favorable than MDM-based coding
Impact: Time-based coding for 99305 requires 35 minutes; if you spend 50+ minutes, consider 99306 ($183.79) for 45% higher reimbursement
Clearly document moderate MDM elements: multiple chronic conditions being addressed, prescription drug management, and review of external records or test results
Impact: Insufficient MDM documentation often results in downcoding to 99304 ($94.96), reducing payment by $33.46 per encounter
Bill 99305 only once per admission; subsequent visits use 99307-99310 codes even if by different provider in same group
Impact: Billing 99305 for subsequent visits will result in claim denial; proper use of 99307-99310 ensures consistent payment stream
Verify patient admission date and ensure you are the first provider rendering comprehensive care; if patient already seen by another provider, use subsequent care codes
Impact: Multiple providers billing initial visit codes for same admission triggers audits and recoupment of full payment
Link appropriate ICD-10 codes supporting moderate complexity: multiple chronic conditions, post-operative care, or acute-on-chronic diagnoses
Impact: Diagnosis coding must support medical necessity; misalignment can trigger denials or medical review delaying payment 30-60 days
For Medicare Part B billing, confirm patient is not in Medicare Part A SNF benefit period, as this affects billing responsibility
Impact: Services during Part A SNF stay may be facility responsibility under PPS; incorrect billing results in denial and potential compliance risk

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Frequently asked questions

What is the difference between CPT 99305 and 99306?

CPT 99305 requires moderate complexity medical decision-making or 35 minutes of time, while 99306 requires high complexity MDM or 45 minutes. The reimbursement difference is significant: 99305 pays $128.42 versus $183.79 for 99306. Choose the code that accurately reflects the documented complexity or time spent.

How much does Medicare pay for CPT 99305 in 2025?

Medicare pays $128.42 for CPT 99305 in 2025 based on the national average non-facility rate. The total RVU is 3.97 (2.5 work RVU + 1.31 PE RVU + 0.16 MP RVU) multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by locality based on geographic adjustments.

Can you bill 99305 more than once for the same patient?

No, CPT 99305 can only be billed once per nursing facility admission. If you see the patient again during the same facility stay, you must use subsequent nursing facility care codes 99307-99310. If the patient is discharged and later readmitted, a new 99304-99306 code may be appropriate for the new admission.

What level of medical decision-making is required for 99305?

CPT 99305 requires moderate complexity medical decision-making, which typically involves multiple problems or chronic conditions being addressed, limited complexity data review (such as reviewing external records or ordering tests), and moderate risk of complications or treatment options. This falls between low complexity (99304) and high complexity (99306).

Can nurse practitioners and physician assistants bill CPT 99305?

Yes, nurse practitioners and physician assistants can bill CPT 99305 within their scope of practice and state regulations. Medicare reimburses NPPs at 85% of the physician fee schedule rate when billing under their own NPI, which would be $109.16 for 99305. Some states and payers may have additional requirements or restrictions.

How many minutes are required to bill 99305 based on time?

CPT 99305 requires 35 minutes of total time spent on the date of encounter when using time-based coding. Total time includes face-to-face and non-face-to-face time spent on care related to that encounter on that day, including reviewing records, documenting, and coordinating care. If you spend significantly more time (45+ minutes), consider coding 99306 instead.

What are common documentation errors that lead to 99305 claim denials?

Common errors include: failing to document it is the initial visit for this admission, insufficient MDM elements to support moderate complexity, billing 99305 when patient already seen by another provider in your group, unclear admission date, lack of medical necessity support, and billing during Medicare Part A SNF benefit periods when consolidated billing applies. Always verify you are the first comprehensive assessment and document all MDM elements clearly.